Case Study: Polyendocrine Metabolic Ovarian Syndrome (PMOS)

Case Study: Polyendocrine Metabolic Ovarian Syndrome (PMOS)

Client: 29-year-old female

Initial presentation: The client, a 29-year-old female, presents with irregular menstrual cycles occurring every 40-50 days, progressive weight gain over the past four years, inflammatory acne affecting the jawline and chin, and mild facial hair growth.

She reports intense carbohydrate cravings in the afternoon, energy crashes after meals, and difficulty losing weight despite running four times per week.  She experiences occasional anxiety and poor self-esteem due to changes in her skin and unwanted hair growth.

Medical history includes childhood eczema and a family history of type 2 diabetes.  She takes no regular medications and has no known allergies.

Her diet is high in refined carbohydrates and pre-packaged snacks due to convenience during work hours.  Water intake averages 2 L daily, sleep averages 7 hours per night and occupational stress is reported as moderate to high.

Naturopathic assessment: 29-year-old female presents with irregular menstrual cycles, progressive weight gain, facial acne and mild facial hirsutism.  Symptoms are consistent with PMOS, likely caused by insulin resistance, hyperandrogenism, ovulatory dysfunction and chronic low-grade inflammation. 

Key factors considered:

  • Insulin resistance - Hyperinsulinaemia is a primary driver of PMOS.  Insulin works synergistically with luteinising hormone (LH) to stimulate ovarian and androgen production.  At the same time, insulin suppresses hepatic sex-hormone binding globulin (SHBG), increasing the volume of free testosterone in circulation.  Elevated circulating androgens contribute to acne, hirsutism, disrupted follicular development and menstrual irregularity.
  • Hyperandrogenism - Excess androgen production contributes to irregular ovulation, acne, hirsutism and weight gain.  Androgens promote preferential accumulation of adipose tissue, which in turn secretes high concentrations of pro-inflammatory cytokines and adipokines.  Reducing insulin resistance and supporting endocrine regulation are central to regulating androgen levels.
  • Chronic inflammation - Low-grade systemic inflammation is increasingly recognised as contributing to insulin resistance, oxidative stress and impaired ovarian function.  Dietary quality, gut health and adipose tissue dysfunction may all contribute to inflammatory load.
  • Hypothalamic-pituitary-adrenal (HPA) axis dysregulation - Chronic stress and elevated cortisol may worsen insulin resistance, increase inflammatory signalling and negatively influence reproductive hormone balance.
  • Gut health - Alterations in the gut microbiome may influence systemic inflammation, glucose metabolism, androgen metabolism, insulin sensitivity and obesity.  Improving gastrointestinal function may provide broader endocrine-metabolic benefits.

Herbal medicine:

Ashwagandha (Withania somnifera) - An adaptogenic herb that supports stress resilience, HPA axis regulation and healthy inflammatory signalling.

Cinnamon (Cinnamomum verum) - Clinically shown to improve serum glucose levels and insulin sensitivity, alongside reductions in body weight, in individuals with PMOS.

Liquorice (Glycyrrhiza glabra) - May assist in reducing androgen activity by inhibiting androgen synthesis enzymes, including 17β-hydroxysteroid dehydrogenase and 17,20-lyase, while stimulating the effects of aromatase, reducing serum testosterone.

Nigella (Nigella sativa) - Clinically shown to significantly improve fasting blood glucose and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR).  Nigella is also associated with improved menstrual regularity by reducing the interval between menstrual cycles and increasing the duration of menstruation.

Paeony (Paeonia lactiflora) - Traditionally combined with Liquorice to support menstrual regularity and reduce signs of androgen excess through modulation of ovarian steroidogenesis.

Herbal formula - 500 mL

  • Ashwagandha (Withania somnifera) 3:2 50 mL
  • Cinnamon (Cinnamomum verum) 1:4 125 mL
  • Liquorice (Glycyrrhiza glabra) 1:1 50 mL
  • Nigella (Nigella sativa) 1:2 150 mL
  • Paeony (Paeonia lactiflora) 1:2 125 mL

Dosage: 7.5 mL twice daily (BD).  Take with food, morning and night.

Note: Client is advised to drink one glass of water with each dose of herbal medicine, to support the liver and kidneys natural processing of alcohol.  She was also advised that she will likely need to take the herbal formula for at least three months to assess efficacy.

Additional recommendations:

Dietary modifications 

  • Move towards a Mediterranean-style dietary approach - Transitioning toward a predominantly whole-food rich diet in vegetables, legumes, olive oil, nuts and seeds and oily fish to support glucose regulation, modulate the gut microbiome and reduce inflammation.
  • Aim for 25-30 g protein at each meal - To improve satiety, regulate blood glucose responses, reduce postprandial glucose fluctuations and stabilise energy levels throughout the day.
  • Increase daily soluble fibre intake - Include oats, legumes, chia seeds and flaxseeds to support insulin sensitivity, glycaemic control, lipid metabolism and body weight regulation.  These benefits are largely driven by microbial fermentation in the large intestine, which produces short-chain fatty acids that regulate inflammation, appetite and metabolic signalling.
  • Drink two glasses of spearmint tea daily - Consumption of two cups of spearmint tea daily has shown reductions in free and total testosterone and improvements in hirsutism in small clinical studies.

Lifestyle modifications 

  • Replace two of the four weekly runs for resistance training sessions - Resistance training is clinically indicated for improving insulin sensitivity, as increased skeletal muscle mass improves glucose disposal and reduces insulin resistance.  A combination of resistance (weight training) and aerobic (running) exercise is one of the most effective interventions for improving metabolic health in PMOS.
  • Establish a consistent sleep routine - Aim for 7.5-9 hours of sleep each night to improve insulin sensitivity, appetite signalling, cortisol activity and reduce inflammation.  Avoid blue light exposure one hour before bed, maintain consistent sleep times and avoid caffeine after midday to improve sleep quality and reduce nighttime wakefulness.  Consider using a herbal sleep product, such as Kiwiherb Sound Asleep, for a short period of time to shift the sleep pattern.
  • Incorporate stress management practices - During chronic stress, activation of the hypothalamic pituitary gonadal (HPG) axis disrupts gonadotropin-releasing hormone (GnRH) pulsatility, resulting in reduced LH and FSH secretion.  This impairs follicular maturation and can consequently inhibit or delay ovulation.  Mind-body interventions such as mindfulness-based stress reduction, yoga, breathwork and counselling have demonstrated clinical improvements in psychological outcomes and, in some cases, metabolic markers. 
  • Track menstrual cycle symptoms to identify ovulation - Encouraging regular symptom tracking can help individuals with PMOS become more familiar with their menstrual cycle and recognise signs of ovulation, even when cycles are irregular.  Recording changes in cervical mucus, basal body temperatures, menstrual bleeding patterns, one-sided lower abdominal pinching (mittelschmerz) and premenstrual symptoms can provide valuable insights into cycle variability and ovulatory function.

Supplements 

  • Myo-inositol (2000-4000 mg/day) - Myo-inositol is one of the most well-studied supplements for PMOS, demonstrating improvements in both metabolic and reproductive outcomes.  Clinical benefits include improved insulin sensitivity, restoration of ovulation, improved menstrual regularity and improved oocyte quality.  Myo-inositol shares clinical and hormonal benefits similar to metformin, without the mild gastrointestinal side effects.
  • Magnesium glycinate (300-400 mg/day) - Magnesium acts as a co-factor in several enzymatic processes that support metabolic balance.  It plays a role in glucose metabolism and insulin receptor function.  Magnesium glycinate also reduces central nervous system (CNS) excitability by modulating NMDA receptor activity while enhancing GABA-mediated inhibitory signalling.  The glycine component provides additional calming effects by further promoting inhibitory neurotransmission, helping to slow neural activity, relax the mind and support restful sleep.  Magnesium glycinate is highly bioavailable and generally well-tolerated.
  • Vitamin D (1000-4000 IU/day) - Vitamin D deficiency is highly prevalent in PMOS, estimated in about 67-85% of individuals.  Correction of deficiency may improve insulin sensitivity, ovarian reserve, menstrual irregularity and inflammatory balance and decrease serum testosterone in PMOS.
  • Omega-3 fatty acids (EPA/DHA 1000-2000 mg/day) - The significant anti-inflammatory effects of omega-3 FAs provide a plausible mechanistic basis for their ability to modulate insulin resistance driven by chronic inflammation.  Omega 3 FAs have been clinically shown to improve LH, total testosterone, SHGB, CRP and total antioxidant capacity in women with PMOS.

Follow-up:

After four weeks, the client reported improved energy throughout the day, with fewer afternoon energy crashes and greater satiety following meals.

There were no changes in menstrual cycle length, although this is to be expected as hormonal regulation occurs gradually through complex feedback mechanisms.  A minimum of three months of consistent treatment is generally required before meaningful changes can be assessed.  Acne severity had improved slightly, with fewer inflammatory lesions along the jawline.  Hirsutism remains unchanged but is expected to improve with continued treatment.

The client had committed to meal prepping her weekly work lunches that were high in protein and fibre, noting a reduced desire to snack on carbohydrate-rich foods during the afternoons.  She had also started incorporating resistance training twice weekly and was enjoying the variety in her exercise routine.  Sleep quality had improved following implementation of an evening routine, averaging 7.5-8 hours nightly. 

The client had adhered well to the herbal formula and was advised to continue for a further two months.  She was referred to her GP for ongoing monitoring of reproductive hormones and metabolic markers. 

The client reported difficulty remembering to track her symptoms and expressed doubts about her ability to consistently incorporate symptom monitoring into her routine.

Regulating insulin signalling and glucose metabolism remains the primary treatment priority.  Following a further two months of treatment, the addition of a single herbal formula with Chaste tree (Vitex agnus-castus) may be considered to further support ovulation and shorten menstrual length.

 

 

Back to blog